Continuous Heparin Research Articles

No impact of endogenous prothrombotic conditions on the risk of central venous line‐related thrombotic events in children: results of the KIDCAT study (KIDs with Catheter Associated Thrombosis)

Central venous lines (CVLs) are the major exogenous risk factor for deep venous thrombosis (DVT) in children. The study objective was to assess whether endogenous prothrombotic conditions contribute to the risk of CVL-related DVT in children. This was a cohort study of consecutive children with heart disease requiring CVLs for perioperative care. CVLs were inserted percutaneously in the upper venous system and patients received prophylaxis with continuous unfractionated heparin (50ukg(-1) d(-1) ). Blood samples to test for prothrombotic conditions were collected prospectively and assayed in a blinded fashion. Outcome assessment was by screening for DVT by venography, venous ultrasound and echocardiography. The study population consisted of 90 children, median age 2.7years (0months-18years). Prevalence rates of antithrombin deficiency, protein C deficiency, protein S deficiency, heterozygous factor V Leiden, prothrombin G20210A mutation, methylentetrahydrofolate C677TT genotype, hyperhomocysteinemia, lupus anticoagulant, anticardiolipin antibodies and increased levels of lipoprotein (a) were within the range reported for the general population. At least one prothrombotic condition was present in 38% of children and combined abnormalities in 8%. The incidence of DVT was 28% (25/90), and most DVTs were asymptomatic. None of the prothrombotic conditions showed a significant association with DVT. The population attributable risk (i.e. the risk of DVT in the overall population attributable to a specific condition) did not exceed 2.2%. Prothrombotic conditions did not have an important impact on the risk of DVT in children with short-term CVLs. The results of the study suggest that screening for prothrombotic conditions is not justified in this setting.

Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion.

BackgroundThrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications.MethodsThis was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA).ResultsSome 749 procedures in 644 patients of median age 73 years were studied; 353 (47·1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38·8 per cent, acute arterial thrombosis in 32·2 per cent, embolus in 22·3 per cent and popliteal aneurysm in 6·7 per cent. Concomitant heparin infusion was used in 63·2 per cent. The mean dose of rtPA administered was 21·0 mg, with a mean duration of 25·2 h. Technical success was achieved in 80·2 per cent. Major amputation and death within 30 days occurred in 13·1 and 4·4 per cent respectively. Bleeding complications occurred in 227 treatments (30·3 per cent). Blood transfusion was needed in 104 (13·9 per cent). Three patients (0·4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation-free survival was 83·6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2·98; P <0·001). Independent risk factors for fasciotomy were severe ischaemia (OR 2·94) and centre (OR 6·50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0·30; P = 0·003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3·82) and renal insufficiency (OR 3·86).ConclusionBoth treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra-arterial thrombolysis appeared to offer no advantage.

A Retrospective Study of Continuous Renal Therapy and Anticoagulation in Patients with Hemorrhagic Fever with Renal Syndrome

Abstract Objective To observe the application of continuous renal replacement therapy (CRRT) and heparin anticoagulation in patients with HFRS, and to explore a more suitable anticoagulant strategy. Methods Eighty-five severe-type patients (severe group) and 71 critical-type patients (critical group) were enrolled in this study. The frequency of CRRT was compared between the two groups; the frequency of CRRT treated with and without heparin anticoagulation and the frequency of hemorrhage and channel blood clotting induced by the two anticoagulant strategies were observed. Results The frequency of CRRT in the critical group was higher than that in the severe group (P ＜ 0.001). The frequency of CRRT initiated during the overlapping phases in the critical group was significantly higher than that of the severe group (P = 0.032). The total times of CRRT was 103, and 70 of them were treated with heparin anticoagulation. The frequencies of hemorrhage induced by heparin anticoagulation and no heparinization were 16 and 0, respectively, and the frequencies of channel blood clotting were 2 and 4, respectively. Conclusions CRRT has been used extensively in the critical-type patients with HFRS. The heparin anticoagulation and no anticoagulant strategies should be used more rationally in patients treated with CRRT, according to the clinical characteristics of the disease.

Training in Placement of Peripherally Inserted Central Catheters in the Neonate

Abstract This is an instructional guide on the placement of a peripherally inserted central catheter (PICC) in an infant. This resource was developed following an iterative review process based on ...

Accidental Intra-arterial Cannulation: an Unusual Case.

Dear editor, Mrs X, 21 years old G3P2 with premature rupture of membranes at 41 weeks gestation, had intravenous cannulation in cubital fossa for oxytocin augmentation. Oxytocin infusion was continued for 10 h. Thereafter, she was given intravenous injections of ampicillin and gentamicin. Immediately after injection, oedema of the forearm was noted which was thought to be due to extravasation of drug. Cannula was immediately removed, and magnesium sulphate ointment was applied locally. After 4 h, massive oedema and cyanosis were noticed in the forearm and hand distal to the cannula with absent radial pulsations, leading to a provisional diagnosis of brachial artery thrombosis. Urgent vascular surgeon consultation was obtained. By this time, cervix was fully dilated and patient delivered vaginally a 3-Kg baby, following which thromboembolectomy was done. Post thromboembolectomy, ultrasound Doppler revealed short segmental thrombus of the right brachial artery in distal one-third of arm; ulnar artery patent for only a segment of 3 cm from its origin and radial artery and veins patent throughout. Postoperative care included broad spectrum antibiotics, vasodilators, anticoagulants, limb elevation and dressings. Blisters were noticed over the dorsum of hand on postnatal day 2; diagnosis of compartment syndrome was made for which fasciotomy was done. Repeated ultrasound Doppler after 2 months revealed occlusion of short segment of right brachial artery in cubital fossa, occlusion of right ulnar artery in forearm with multiple collaterals in forearm. Patient had complete resolution of sequelae with complete functioning of hand in 3 months. Accidental intra-arterial anaesthetic drug injections have been reported previously [1]. It has been proposed that lipid soluble drugs are more problematic, and brachial artery is associated with more tissue damage than radial or ulnar [1]. The immediate clinical presentations include pain, pallor in hand and cyanosis of fingers followed by extensive oedema of hand and forearm within 5 h. Extensive injury includes nerve damage, compartment syndrome, thrombosis and gangrene leading to eventual amputation [2]. In this case, significant time elapsed before arterial catheterisation was discovered resulting in disastrous outcome. In summary, vigilance is the best therapy. An indwelling catheter not functioning properly should never simply be assumed to be positional. Alarming signs include marked increase in blood pressure on flushing the line, bright red appearance of blood, more intense pain than expected, distal signs of ischaemia, manual palpation of arterial pulse proximal to the catheter and retrograde pulsatile blood flow. Diagnosis is by pressure transducer or blood gas analysis. Treatment recommendations include continuous heparin infusion for 24 h which, if done immediately, leads to no sequelae; sympathetic blockage with brachial plexus block, stellate ganglion block and general anaesthesia for further sympatholysis, postoperative limb elevation and maintenance of warmth, intra-arterial vasodilators and surgical exploration to extract thrombus and fasciotomy [2]. To conclude, a high index of suspicion of intra-arterial cannulation can prevent disastrous consequences. It is recommended that if suspicion is high, intravenous catheterisation should be repeated unless situation is extremely dire and no other intravenous access is readily obtainable.

Early Postoperative Anticoagulation by Enoxaparin after Mechanical Aortic Valve Replacement

Background: The use of low molecular weight heparin for early anticoagulation after mechanical aortic valve replacement is still a matter of debate even more that the early postoperative phase is associated with maximum of thrombo-embolic and bleeding risks. The objective of this study is to verify the efficacy and the safety of low molecular weight heparin for the early anticoagulation after mechanical aortic valve replacement. Methods and Results: It is a prospective study conducted over 6 months and interested 40 consecutive patients (32 male and 8 female) with a mean age 53.83 ± 16.93 years (19-75 years) who underwent a mechanical aortic valve replacement and received enoxaparin as bridging therapy between continuous unfractionated heparin and fully effective vitamin K antagonist therapy. There was no in-hospital death and no in-hospital thromboembolic events. We report 2 major bleeding events (5%). Conclusion: The use of low molecular weight heparin should be an alternative to explore for early anticoagulation after valve heart surgery and the results of our study must be verified by large randomized studies before drawing any hasty conclusions.

Left Atrial Appendage Percutaneous Closure with Watchman Device: Single Centre Experience and a Review of Literature

Background: Left Atrial Appendage (LAA) is the main source of left atrial thrombi causing embolic strokes in patients with Non Valvular Atrial Fibrillation (NVAF). Since many patients carry contraindications to Oral Anticoagulation (OAC), percutaneous devices for closure of LAA have been introduced, to avoid peripheral thromboembolism in absence of OAC. Methods: From March 2012 to March 2014 we enrolled patients which had permanent and persistent NVAF and high thromboembolic risk with absolute contraindication to OAC. They were subjected to insertion of Boston Scientific Watchman device in LAA under transesophageal and fluoroscopic guide, with continuous heparin administration to maintain constant activated clotting time (ACT) of 300-350 sec and under general anesthesia. Patients were discharged with indication to double antiplatelet therapy with Aspirin and Clopidogrel for 6 months and Aspirin thereafter, avoiding Warfarin at all. Follow-up Transesophageal Echocardiography (TEE) was performed 2 months, six months and 12 months after implantation. Results: We enrolled 21 patients, aging 49 to 80 yrs. (mean 67.61± 8.2), with high thromboembolic risk (CHADsVasc 3.23 ± 1.33), and with different contraindications to OAC, in most cases due to severe bleeding risk and difficulty in keeping stable INR values (HASBLED 3 ± 1.09). The mean size of the device implanted was 24.75 ± 2.56 mm, the mean total procedure time was 67.78 ± 18 min, the mean fluoroscopy time was 16.81 ± 2.53 min. In all cases LAA was successfully occluded at first TEE, performed within 2 months from the procedure, while we noticed a trend towards development of non-pathological leaks in the next control TEEs, with patients always free from embolic events at mean follow-up of 13.09 ± 6.04 months. Moreover, we noticed a trend towards reduction of left atrial spontaneous echo contrast after LAA closure. Conclusion: Percutaneous LAA closure followed by administration of DAPT appears to be safe and effective at mid-term follow-up in patients with absolute contraindications to OAC. Long term safety and efficacy will be demonstrated with longer follow-up and with more patients enrolled.

Good Clinical Outcome After Accidental Intra-arterial Injection of Flunitrazepam Tablets in 16 Drug Abusers with Critical Limb Ischaemia

Inadvertent intra-arterial injection of flunitrazepam tablets intended for intravenous use by drug abusers has devastating effects. We report here on the clinical outcome of 16 drug abusers developing critical limb ischaemia after flunitrazepam injection. Treatment combined immediate analgesia and anticoagulation, long-lasting local thrombolysis and vasodilatation, antibiotic prophylaxis, and physical mobilization. The immediate bolus injection of 5,000 IU heparin was followed by a continuous heparin infusion up to the target partial thromboplastin time. Under arteriographic control local intra-arterial infusion with alternating 4-h cycles of 5 mg recombinant tissue plasminogen activator followed by 5 μg prostaglandinE1 (PGE1) was performed for 24-48 hours. Subsequently, 60 μg PGE1 was applied once daily. Drug abusers, having been injected with 4-30 mg flunitrazepam, were treated 3-72 hours after the accident, with six of them not being treated until after 24 hours. All showed a high tissue ischaemia score. At the time of being discharged from hospital 13 patients had a normal extremity. In one patient, first receiving treatment 72 hours after injection, minor amputation of fingers was necessary. The life of the patient who injected 30 mg flunitrazepam in the leg was saved after hip disarticulation. One patient developed neurological dysfunction in the affected toes. Intensive treatment after inadvertent intra-arterial drug injection normalized the affected extremity in most drug abusers, even after the late onset of therapy.

Management of Peripherally Inserted Central Catheters (PICC) in Pediatric Heart Failure Patients Receiving Continuous Inotropic Support

The study aim was to evaluate present practice of maintaining PICC line patency in pediatric heart failure patients receiving continuous inotropes by comparing one cohort receiving low dose continuous heparin with one receiving no heparin. A case control retrospective chart review compared the two cohorts on duration of patency (measured in days) and need for thrombolytic agents. Median duration of patency for the heparin group was 24 days versus 16 days for the no heparin group (p=0.07). Use of thrombolytic agents was 28% in the heparin group compared to 50% in the no heparin group (p=0.08). Although not statistically significant, findings were clinically significant and supportive of current practice.

Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı

Free fl oating right atrial thrombi are associated with high mortality. Although trombolysis and surgical trombectomy are recommended, their management is still the subject of debate. A 78 year old woman with a history of stroke a month ago, presented to the emergency department with palpitation. Transthoracic echocardiography revealed a large free-fl oating right atrial thrombus. After intravenous bolus of 5000 IU unfractional heparin she was prepared for cardiac surgery because of contraindications for trombolytic therapy. About 90 minutes after unfractional heparininfusion, we decided to check the thrombus, and realised that it was not there anymore, but there was a slight enlargement in right cardiac chambers. Patient was hemodynamically stabil. Contrast enhanced computerized tomography demonstrated multiple small fi lling defects in the subsegmental branches of pulmonary tree. Surgery was cancelled and Doppler ultrasonography revealed deep venous thrombosis in the left lower limb. After 72 hours of continuous unfractional heparin infusion, warfarin was started. During the hospitalization there was not any complication. Patient was stabil for the following three months. This is a report of free fl oating right atrial trombus origined from deep lower extremity veins and treated by unfractional heparin without any clinical deterioration. In this particular case we think that unfractional heparin might have partly worked because of fresh, unorganised and fragil thrombus. In patients with right atrial free fl oating thrombus, especially when thrombolytic therapy is contraindicated and surgical mortality is high, it may be an alternative to start unfractional heparin and check the thrombus after several hours before the surgery.

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Introduction: Central venous catheter (CVC) occlusion is the most common CVC complication among pediatric patients and may increase morbidity, disrupt therapy, and necessitate catheter removal Methods: This is a retrospective medical record review of all patients admitted to any intensive care unit at Boston Children's Hospital from March 1, 2011 to December 31, 2012 who received recombinant tissue plasminogen activator (rt-PA), hydrochloric acid, ethanol, and/or sodium bicarbonate for CVC occlusion. Occlusion events were defined by administration of a pharmacologic clearance agent for catheter clearance within at 24-hour period. Restoration of CVC patency was defined as ability to infuse and/or aspirate via CVC. Patient, catheter and treatment characteristics were analyzed. Results: 188 subjects, admitted to one of four critical care units with different unit-based CVC maintenance protocols, experienced a total of 323 CVC occlusion events during the study time period. Administration of a pharmacologic clearance agent restored CVC patency in 224 events (69.3%). Recurrent CVC occlusion occurred in 66 subjects (35.1%). Age less than 4 years (63.7% of occlusion events), exposure to mechanical ventilation (84.2%), narcotic infusion (64.7%), benzodiazepine infusion (67.8%), and CVC size of 4 French or smaller (74.9%) were associated with CVC occlusion. Events were least frequent with the use of continuous heparin infusion for CVC maintenance, (3.4% of occlusion events) as compared to events occurring with the use of intermittent heparin flush maintenance, saline flush, and/or continuous non-heparin containing infusion. Catheter removal occurred in 19 subjects (10.1%). Clinically symptomatic venous thromboembolism (VTE) occurred in 5 subjects in the setting of CVC occlusion (2.6%). Conclusions: CVC occlusion is associated with non-modifiable patient and necessary treatment characteristics. Use of standardized CVC maintenance with continuous heparin containing infusions may decrease morbidity associated with CVC occlusion.

Lack of difference between continuous versus intermittent heparin infusion on maintenance of intra-arterial catheter in postoperative pediatric surgery: a randomized controlled study

OBJECTIVE: To compare two systems of arterial catheters maintenance in postoperative pediatric surgery using intermittent or continuous infusion of heparin solution and to analyze adverse events related to the site of catheter insertion and the volume of infused heparin solution. METHODS: Randomized control trial with 140 patients selected for continuous infusion group (CIG) and intermittent infusion group (IIG). The variables analyzed were: type of heart disease, permanence time and size of the catheter, insertion site, technique used, volume of heparin solution and adverse events. The descriptive variables were analyzed by Student's t-test and the categorical variables, by chi-square test, being significant p<0.05. RESULTS: The median age was 11 (0-22) months, and 77 (55%) were females. No significant differences between studied variables were found, except for the volume used in CIG (12.0±1.2mL/24 hours) when compared to IIG (5.3±3.5mL/24 hours) with p<0.0003. CONCLUSIONS: The continuous infusion system and the intermittent infusion of heparin solution can be used for intra-arterial catheters maintenance in postoperative pediatric surgery, regardless of patient's clinical and demographic characteristics. Adverse events up to the third postoperative day occurred similarly in both groups. However, the intermittent infusion system usage in underweight children should be considered, due to the lower volume of infused heparin solution [ClinicalTrials.gov Identifier: NCT01097031].

Pulmonary thromboembolism in lung surgery: use of unfractionated heparin

While thoracic surgeons occasionally encounter pulmonary thromboembolism, the use of unfractionated heparin may cause adverse effects. We assessed a series of 323 consecutive pulmonary operations performed during 4 years from 2008 to 2011. All patients were given elastic stockings and intermittent pneumatic compression. During the first 2 years (2008-2009), none of the 169 patients received unfractionated heparin. In the second 2-year period (2010-2011), 135/154 patients received subcutaneous unfractionated heparin, either 5000 units (n = 37) or 2500 units (n = 93) twice daily for 3 days, or continuous intravenous unfractionated heparin (n = 5). The epidural catheters were withdrawn 6 h or more after unfractionated heparin use. Among patients without postoperative unfractionated heparin, 8 (42.1%) had a bleeding risk and 5 (26.3%) had limited operative time. One (0.6%) patient developed pulmonary thromboembolism during 2008-2009, but none had this complication during 2010-2011. The adverse outcome of intrathoracic bleeding occurred in one (2.7%) of the patients given 5000 units of unfractionated heparin, but no epidural hematomas occurred in these patients. Patients undergoing thoracic surgery at low risk of bleeding may receive unfractionated heparin to prevent pulmonary thromboembolism while avoiding epidural complications.

Good Clinical Outcome After Accidental Intra-arterial Injection of Flunitrazepam Tablets in 16 Drug Abusers with Critical Limb Ischaemia

Inadvertent intra-arterial injection of flunitrazepam tablets intended for intravenous use by drug abusers has devastating effects. We report here on the clinical outcome of 16 drug abusers developing critical limb ischaemia after flunitrazepam injection. Treatment combined immediate analgesia and anticoagulation, long-lasting local thrombolysis and vasodilatation, antibiotic prophylaxis, and physical mobilization. The immediate bolus injection of 5,000IU heparin was followed by a continuous heparin infusion up to the target partial thromboplastin time. Under arteriographic control local intra-arterial infusion with alternating 4-h cycles of 5mg recombinant tissue plasminogen activator followed by 5μg prostaglandinE1 (PGE1) was performed for 24-48 hours. Subsequently, 60μg PGE1 was applied once daily. Drug abusers, having been injected with 4-30mg flunitrazepam, were treated 3-72 hours after the accident, with six of them not being treated until after 24 hours. All showed a high tissue ischaemia score. At the time of being discharged from hospital 13 patients had a normal extremity. In one patient, first receiving treatment 72 hours after injection, minor amputation of fingers was necessary. The life of the patient who injected 30mg flunitrazepam in the leg was saved after hip disarticulation. One patient developed neurological dysfunction in the affected toes. Intensive treatment after inadvertent intra-arterial drug injection normalized the affected extremity in most drug abusers, even after the late onset of therapy.

Veno-venous ECMO in ARDS after post-traumatic pneumonectomy

Dear Editor, Post-traumatic pneumonectomy is rare, but burdened by high mortality (50–80 %) and high morbidity, with a complication rate of [85 %, most commonly pneumonia and respiratory failure [1]. Life-threatening acute respiratory distress syndrome (ARDS) can develop, and the worst outcome is associated with right pneumonectomy [2]. Extracorporeal membrane oxygenation (ECMO) is a rescue option in ARDS that allows for protective mechanical ventilation and potentially less ventilator-induced damage [3]. In the past, trauma cases requiring anticoagulation for ECMO implantation posed a clinical dilemma that has now been partially overcome with the advent of latest generation devices. We report a case of multifactorial ARDS (pneumonia, polytransfusion, and fluid overload) after right pneumonectomy due to blunt chest trauma in which the patient was non-responsive to protective ventilation and conventional therapy [4]. The patient survived with early implantation and 29 days of ECMO support. A 25-year-old male (170 cm, 61 kg) was admitted to another facility with major blunt thoracic trauma causing right hemothorax, right main bronchial disruption, left pneumothorax, and pneumomediastinum. Surgical treatment consisted of right pneumonectomy, left chest drainage, and tracheostomy. Despite lung-protective ventilation, the patient developed ARDS, with hypoxic–hypercapnic respiratory failure [partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) 40 at 36 h]. A PaO2/ FiO2 ratio of\100 with a FiO2 of 1.0 for more than 6 h indicates that a patient has a [80 % risk of death (Extracorporeal Life Support Organization guidelines) (Fig. 1). The referring center requested a consultation, and despite the recent trauma and surgery, we decided to start the patient on veno-venous ECMO (VV-ECMO) which achieved stabilization and allowed the patient to be safely transported about 200 km by helicopter to our institute. Vessel cannulation [18 Fr return (jugular) and 24 Fr drainage (femoral)] was performed after the administration of a heparin bolus (80 IU/kg). VVECMO support (miniaturized tip-totip heparin-coated circuit; Cardiohelp System; Maquet, Rastatt, Germany) was initiated, with the initial goal of achieving a blood flow of about 4 l/ min (3,000 rpm and 2 l/min of sweep gas flow) in order to provide maximal oxygenation support, but avoid iatrogenic alkalosis. Protective mechanical ventilation for transport was a FiO2 of 40 %, peak inspiratory pressure (PIP) of 20 cm H2O, positive end-expiratory pressure (PEEP) of 10 cm H2O, and respiratory rate (RR) of 10 breaths/min (Oxylog 3000 Plus; Draeger, Menlo Park, CA). On arrival at our institute, after a few hours of ECMO, gas exchange parameters were adequate (pH 7.34, PaO2 116 mmHg, PaCO2 58 mmHg). Microbiological screening revealed colonization by Acinetobacter baumannii (multi-drug resistant), which was confirmed by the swab test and bronchoalveolar lavage. Continuous heparin infusion was initiated to maintain an activated partial thromboplastin time of 40–50 s, and an

Short‐Term In Vivo Performance of the Cleveland Clinic PediPump Left Ventricular Assist Device

The PediPump was implanted in six healthy lambs (mean 25.6 ± 1.4 kg) between the left ventricular apex and the descending aorta to evaluate in vivo performance for up to 30 days. Anticoagulation was achieved by continuous heparin infusion. Three animals were euthanized prematurely, two because of respiratory dysfunction and one because of deteriorating pump performance resulting from thrombus formation inside the pump. Three lambs were electively sacrificed 30 days after implantation; all had stable hemodynamics and minimal hemolysis, as indicated by low plasma free hemoglobin (2.5 ± 3.1 mg/dL). Mean 30-day pump flow was 1.8 ± 0.1 L/min at a pump speed of 12 200 ± 400 rpm. Neither activated clotting time nor activated partial thromboplastin time followed the changes in heparin dose. At necropsy, depositions were observed at the front (n = 1) and rear rotor axial positioning stops (n = 4); improved polishing techniques on the stationary stop surfaces and the addition of a hard-carbon, thin-film coating on the rotating stop of the pumps used for the last two experiments addressed the deposition seen earlier. In conclusion, the PediPump showed excellent hydraulic performance and minimal hemolysis during support for up to 30 days. Depositions observed at the axial positioning stops in earlier experiments were addressed by design and material refinements. We continue to focus on developing effective anticoagulation management in the lamb model as well as on further evaluating and demonstrating pump biocompatibility.

Early neurological complications after transcatheter closure of atrial septal defect with nitinol wire mesh occluder

Atrial septal defect (ASD) was closed percutaneously in an 18-year-old boy with a 27 mm nitinol wire mesh occluder according to standard procedures. Three hours after the procedure, he presented anxiety attacks, aggression, a vacant stare and a verbal/speaking disorder. Small ischaemic stroke localised in the right temporal/parietal region of the central nervous system was confirmed by computed tomography examination. Activated partial thromboplastin time was then 54 s despite continuous heparin infusion. Heparin dose was increased and symptomatic treatment was introduced (mannitol, furosemide, propofol, haloperidol). The next day, all symptoms disappeared. He remained in good clinical condition, without neurological disorders 1.5 months after the procedure. Complications related to transcatheter ASD closure still exist despite the fulfillment of standard procedural criteria. Frequent coagulogical examinations during and after the procedure are necessary. Close observation and follow-up of treated patients is mandatory.

Défaillance multiviscérale compliquant une pancréatite aiguë au décours d’une hypertriglycéridémie majeure : à propos d’un cas

We report the case of a 42-year-old man admitted for a multi-organ failure with a coma, a hemodynamic instability, a respiratory distress syndrome, an acute renal failure and a thrombocytopenia. The blood samples highlighted a milky serum and allowed to diagnose an acute pancreatitis associated with a major dyslipidemia: hypertriglyceridemia 11,800mg/dL and hypercholesterolemia 1195mg/dL. The CT-scans do not reveal any cerebral abnormalities but highlighted pancreatic lesions without biliary obstruction. A multi-organ failure complicating a severe acute pancreatitis secondary of a major hypertriglyceridemia was mentioned. Despite the absence of clear guidelines, a session of plasma exchange was started in emergency. Symptomatic treatment with protective ventilation, vasopressors, continuous heparin and insulin was continued. The clinical and biological course was good in parallel of the normalization of lipid abnormalities. The patient was discharged at day 17 with a lipid-lowering therapy. We discuss the various treatments available for the management of acute pancreatitis complicating a severe hypertriglyceridemia and their actual relevance in the absence of clear recommendations.

Hepatic Hematoma After Islet Cell Transplantation

Hepatic Hematoma After Islet Cell Transplantation

Impact of Different Types of Resuscitation Fluids on Coagulation and Continuous Venovenous Hemofiltration Hemocompatibility in a Porcine Model

Intensive therapy demanding diseases (organ failure or sepsis) are assumed to be the etiology behind a decreased biocompatibility of extracorporeal systems for renal replacement therapy (RRT). There are also potential interactions between different components of the overall therapy. Volume substitutes are known to influence hemorheology and coagulation. To define a potential net effect of volume substitutes on the hemocompatibility of an RRT, we chose an animal model without interfering pathophysiologies. According to the problem of early filter failure and coagulation disorders in critically ill patients, we focused on the hypothesized interaction between RRT and different volume substitutes with respect to blood cell counts, coagulation parameters and required heparin dose. Forty-eight pigs were assigned to four groups of fluid therapy with either normal saline (NaCl), 6%HES130kD/0.4 (HES130), 6%HES200kD/0.5 (HES200) or 4%gelatin (GEL). Six pigs of each fluid group underwent continuous venovenous hemofiltration (CVVH), the remaining six served as the control group. Anticoagulation was performed with continuous heparin infusion. CVVH was run in a recirculation-mode for 4.5 h to force hemocompatibility reactions, thereafter in a standard-mode for 2 h. During the CVVH-treatment GEL reduced platelet counts and fibrinogen concentration and additionally lowered ATIII levels. Heparin requirements did not differ between different volume substitutes or CVVH and control groups. Severe pathophysiologies are not the only reason for a reduced hemocompatibility of CVVH treatment. Interaction of a particular volume substitute with CVVH should be considered when interpreting study results and evolving new strategies.